Common use of Demonstration Clause in Contracts

Demonstration. The State of Delaware’s Medicaid demonstration project, authorized by CMS pursuant to Section 1115(a) of the Social Security Act. Abuse – For purposes of program integrity, provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid and CHIP program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for health care. Abuse also includes client/member practices that result in unnecessary cost to the Medicaid and CHIP program (see 42 CFR 455.2). Access (as it pertains to external quality review) – The timely use of services to achieve optimal outcomes, as evidenced by the Contractor successfully demonstrating and reporting on outcome information for the availability and timeliness elements defined under 42 CFR 438.68 (Network adequacy standards) and 42 CFR 438.206 (Availability of services). Adverse Benefit Determination – In accordance with 42 CFR 438.400(b), the denial or limited authorization of a requested service, including determinations based on the type or level of service; requirements for medical necessity (see Section 3.4.5 of this Contract), appropriateness, setting, or effectiveness of a covered service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment for a service; the failure to provide services in a timely manner, as defined by the State; the failure of the Contractor to act within timeframes provided in this Contract regarding the standard resolution of Grievances and Appeals; and the denial of a member’s request to dispute a financial liability, including cost sharing, copayments, and other member financial liabilities. Activities of Daily Living (ADLs) – A personal or self-care skill performed, with or without the use of assistive devices, on a regular basis that enables the individual to meet basic life needs for food, hygiene, and appearance, including bathing, dressing, personal hygiene, transferring, toileting, skin care, eating and assisting with mobility.